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a ?i APPLICATION FOR PERMIT - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA y Telephone (209) 466-6781 PERMIT EXPIRES 'I YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welllpump and the Rule§and Regulations of the San Joaquin Local Health District. 7 � rr Jab Address eCGS oc Sr�J City CQ 4f 4c�, -7�� ` s '} Lot Size PM Owner's Name 7�+1�[/�.l Address 2; i7 C ` p �'t— Phone _ Contractor's Name N �'' `� License No. 3d 5,72, Phone Ate-jS 3—S TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filter Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION YDESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence i�Commercial_ Other Number of living units: Number of boorooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/m_ 21- Ga.cvH.c-�' Capacity ``" No. Compartments ' PKG. TREATMENT PLT. ❑ f Method of pis o I Distance to nearest: Well 4�6 Foundation r Property Line l 49V LEACHING LINE pr No. & Length of lines U Total length/size O �° FILTER BED ❑ Distance to nearest: Well Foundation 2-0 r Property Line Oi SEEPAGE PITS E---Depth <S Size Number �. I SUMPS ❑ Distance to nearest- Well3L Q' Foundation �O Property Line DISPOSAL PONDS ❑ I hereby certify that t have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature certifies the following."I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant must ca for 11 q red inspections. Complete drawing on reverse side. Signed Title: Il�c� Date: y. FOR DEPARTMENT USE ONLY Application Accepted by `� Dat¢JArea G Pit Grout Inspection by ate a inal Inspection b Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant . Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO. AMOUNT DUE AMOUNT REMITTED CK# RECEIVED 8Y DATE PERMIT'ND. CASH-- } EEH 3-24 H 1428(REV. 14!931